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MOH/S/IKU/60.16 (RR)

NATIONAL HEALTH AND MORBIDITYSURVEY 2016 :

MATERNAL AND CHILD HEALTH (MCH)

Volume Two : Maternal and Child Health Findings

(NMRR - NMRR-15-511-25359)

Institut Kesihatan Umum, Pusat Kesihatan Negara,Kementerian Kesihatan Malaysia

Institute for Public Health, National Institutes of Health (NIH),Ministry of Health Malaysia

Produced and Distributed by:Institute for Public Health, Ministry of Health, Malaysia

The National Health and Morbidity Survey 2016: Maternal and Child Health,Institute for Public Health,National Institutes of Health,Ministry of Health,Jalan Bangsar,50590 Kuala Lumpur,Federal Territories of Kuala LumpurMalaysia.

Tel: +603-22979400 / +603-22979540Fax: +603-22823114 / +603-22979555

Any enquiries or comments on this report should be directed to:

The Principal Investigator,The National Health and Morbidity Survey 2016,Institute for Public Health,National Institutes of Health,Ministry of Health,Jalan Bangsar,50590 Kuala Lumpur,Federal Territories of Kuala LumpurMalaysia.

Tel: +603-22979400 / +603-22979540Fax: +603-22823114 / +603-22979555

Published by the Institute for Public Health, National Institutes of Health (NIH),Ministry of Health, Malaysia

ii National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

NATIONAL HEALTH AND MORBIDITY SURVEY 2016:MATERNAL AND CHILD HEALTH (MCH)

CORE TEAM MEMBERSThe following persons had contributed in the proposal, planning, logistics, analysis, write-up,discussion on implication, conclusions and/ or drawing recommendations for this report.

(In alphabetical order)Ahmad Nadzri Jai, Aminah Bee Mohd. Kassim, Azah Abdul Samad, Azli Baharuddin, AzrimanRosman, Balkish Mahadir Naidu, Chan Ying Ying, Cheong Siew Man, Chin Yit Siew, Faizah Paiwai,Faridah Abu Bakar, Fatimah Othman, Hamizatul Akmal Abd Hamid, Helen Tee Guat Hiong,Jamilah Ahmad, Junidah Raib, Kawselyah Juval, Lim Kuang Kuay, Madihah Ahmad Puaad,Maisarah Omar, Majdah Mohamad, Maria Safura Mohamad, Mohd Azahadi Omar,Mohammad Aznuddin Abd. Razak, Mohd. Azza Azlan, Mohamad Fuad b Mohamad Anuar,Mohd. Hasnan Ahmad, Mohd Hazrin Hasim @ Hashim, Mohd. Kamal Ariff Abdul Ghani,Muhammad Fadhli Yusoff, Muslimah Yusof, Natifah Che Salleh, Nazrila Hairin Nasir,Nik Mazlina Mohammad, Noor Ani Ahmad, Noraida Mohamad Kasim, Norazizah Ibrahim Wong,Norzawati Yoep, Nor Azian Mohd Zaki, Nurhafizah Sahril, Nurrul Ashikin Abdullah, Nur Azna Mahmud,Nurhafizah bt. Sahril, Nur Shahida Abdul Aziz, Rahama Samad, Rajini Sooryanarayana,Rashadiba Ibrahim, Rashidah Ambak, Rohani Jahis, Rokiah Mohamad, Rosliza Abdul Manaf,Rosnah Sutan, Rozita Ab. Rahman, Ruhaya Salleh, Rusidah Selamat, Sangita Dharshini Terumalay,Santhi Ramasamy, Safurah Jaafar, Shamala Devi Karalasingam, Shubash Shander Ganapathy,Syafinaz Mohd. Sallehuddin, S Maria Awaluddin, Sayan Pan, Siti Nor Fadhilah Zainal Abidin,Tahir Aris, Tuty Aridzan Irdawati Mohsinon, Yaw Siew Lian, Zul Azuin Zulkifli

OTHER MEMBERS(In alphabetical order)Asits Sanna, Azlina Ab. Manan @ Kamaruddin, Izwana bt Hamzah, Noran Hashim,Nurly Zahureen Mustapha, Mohd Ridzuan Janudin, Nazatul Shima Mokhtar, Noraziah Aboo Bakar,Nor Halilah Abdullah, Noorharizan Harun, Norizan Ahmad, Radziah Mohamad, Sazidah Mohd Karli,Siti Khatijah Abdul Rahim, Sophia Mohd Ramli

RESEARCH ASSISTANTS(In alphabetical order)Che Fadillah Che Abd Aziz, Fatin Farzana Amir Zaki, Hasmila Mat Hassan, Lavinia Joan Chong,Maisarah Mat Hasim , Megat Rusydi Megat Radzi, Mohamad Faiz Md Muda, Mohd Firdaus Daud,Muhammad Asyraf Napiah, Muhammad Zuhdi Khiruddin, Noor Hidayah Solmi, Norazlina Muhamad,Nur Amirah Amni Mohamed, Nurshuhada Yang Abu, Puteri Noor Ruzanna Abd Aziz,Shafiq Naim Bin Shahrudin, Sharifah Nur Hanis Syed Noh, Syahirah Azmi,Wan Nurhafizah Mohd Rodzlad

National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings iii

iv National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

This report comprises of two volumes, as follows:

I. Volume I : Methodology and General FindingsII. Volume II : Maternal and Child Health Findings

2016, Institute for Public Health, National Institutes of Health, Ministry of HealthMalaysia. Kuala Lumpur.

ISBN: 978-967-978-983-2387

Suggested citation:

Institute for Public Health (IPH), National Institutes of Health, Ministry of Health Malaysia. 2016. National Healthand Morbidity Survey (NHMS) 2016: Maternal and Child Health. Vol. II: Findings, 2016. pp 272

Disclaimer:

The views expressed in this report are those of the authors alone and do not necessarily represent the opinionsof other investigators participating in the survey, nor the views or policy of the Ministry of Health.

National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings v

ACKNOWLEDGEMENTS

The authors would like to express their appreciation to the Director-General of Health, Malaysia, forhis permission to publish this report. The authors would also like to thank the Director-General ofHealth Malaysia for his enduring support and guidance during the conduct of this survey. Our deepestgratitude to the Director, Economic Planning Unit, Prime Ministers Department for recognising theneed to study various aspects of childrens health, development and education, thereby leading to theimplementation of this study under the umbrella of the National Health and Morbidity Surveys. Oursincere appreciation to the Deputy Director-General (Research and Technical Support), our belovedDirector of the Family Health Development Division and our esteemed Director of the Institute forPublic Health, for their unwavering support, confidence and technical advice throughout the variousstages of the survey.

The National Health and Morbidity Survey 2016, was accomplished with budget supported by theEconomic Planning Unit, Prime Ministers Department, through the National Institutes of Health,Ministry of Health Malaysia. Technical advice was from the Advisory Panel and Steering Committee,consisting of executives and experts from both inside and outside the Ministry of Health. The authorswould like to express our heartfelt thanks to them.

The authors thank all the State Health Directors and all State Liaison Officers who have beeninstrumental in mobilising resources during the data collection phase. The authors also thank allparties who assisted in the implementation of the survey, from the field supervisors, data collectors,nurses, scouts and drivers, without whom the survey would not have been a success.

Last but not least, our sincere appreciation is extended to all respondents who had participated in andcontributed their time and information towards the survey. It is our hope that these valuable findingswill help program leaders and policy makers to better run the various health and educational servicesavailable.

vi National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

TABLES OF CONTENTS

Acknowledgements

List of Tables

List of Abbreviations

IV. Child HealthVaccinationsNeonatal tetanus ProtectionCare of IllnessChild InjuriesCare of Oral Health

V. NutritionLow Birth WeightNutritional Status of ChildrenInfant and Young Child Feeding

VI. Child DevelopmentDevelopmental DelayAutismAccess to Screen TimeEarly Childhood Care and Education

VII. Child ProtectionIndequate CareChild Discipline

VIII. Reproductive HealthAntenatal CareIntra-Partum CareAwareness of and Practice of Natural BirthingPost-natal CarePost-natal Depression Screening

List of Appendices

Appendix 7 : Tables of FindingsAppendix 8 : Operational Definition of Variables

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Table 4.1.2.1 : Sociodemographic profile of successful vs. unsuccessful households ..................Table 4.1.2.2 : Characteristics of children aged 12-23 months ......................................................Table 4.1.2.3 : Prevalence of children age 12-23 months vaccinated with BCG ...........................Table 4.1.2.4 : Prevalence of children age 12-23 months vaccinated with DPT-IPVHib vaccineTable 4.1.2.5 : Prevalence of children age 12-23 months vaccinated with Hep B vaccine ............Table 4.1.2.6 : Prevalence of children age 12-23 months vaccinated with MMR vaccine ............Table 4.1.2.7 : Prevalence of children age 12-23 months with verified complete vaccination,

unvaccinated and incomplete vaccination against any vaccine preventablechildhood disease before the survey and by their first birthday .............................

Table 4.1.2.8 : Reasons for incomplete vaccination ......................................................................Table 4.1.2.9 : Prevalence of children age 12-23 months vaccinated against vaccine preventable

childhood diseases at private facilities before the survey and by their first birthdayTable 4.1.2.10 : Reasons more than half of vaccines were taken at private facilities ......................Table 4.1.2.11 : Source of information on vaccination .....................................................................Table 4.1.2.12 : Vaccine most concerned about ..............................................................................Table 4.1.2.13 : Opinion on vaccination ..........................................................................................Table 4.2.2.1 : Neonatal tetanus protection as seen by percentage of women age 15-49 years

with a live birth in the last 2 years who had received anti-tetanus vaccine duringtheir last pregnancy ................................................................................................

Table 4.2.2.2 : Completed vaccination for Malaysia ......................................................................Table 4.2.2.3 : Completed vaccination by state ..............................................................................

CARE OF ILLNESS (DIARRHOEA & ACUTE RESPIRATORY INFECTIONS)

Table 4.3.2.1 : Sociodemographic characteristics of children 0-59 months affected by illness .....Table 4.3.2.2 : Prevalence of children age 0-59 months with an episode of diarrhoea .................Table 4.3.2.3 : Prevalence of children age 0-59 months with symptoms of acute respiratory

infection (ARI) ........................................................................................................Table 4.3.2.4 : Prevalence of children age 0-59 months reported to have had diarrhoea &

symptoms of acute respiratory infection (ARI): either one or both in the last twoweeks ....................................................................................................................

Table 4.4.2.1 : Sociodemographic characteristics of children age 12-59 months with child injuriesTable 4.4.2.2 : Prevalence of child injuries among children age 12-59 months during the last one

year ........................................................................................................................

Oral Health

Table 4.5.2.1 : Perception on importance of looking after children's oral health ............................Table 4.5.2.2 : Frequency of cleaning/brushing child's teeth or supervision of child's tooth

brushing .................................................................................................................Table 4.5.2.3 : Prevalence of mothers who had ever brought their child for a dental visit ............Table 4.5.2.4 : Timing of child's last dental visit .............................................................................Table 4.5.2.5 : Opinion on timing of child's first dental check-up ...................................................Table 4.5.2.6 : Perception of age of a child's first dental visit ........................................................Table 4.5.2.7 : Willingness to take child for dental treatment upon advice ....................................Table 4.5.2.8 : Reasons for not bringing child for dental treatment ...............................................Table 4.5.2.9 : Prevalence of mothers who had ever received advice from health personnel on

looking after child's oral health ...............................................................................Table 4.5.2.10 : Child's dental visit in relation to perceived importance of child's oral health .........Table 4.5.2.11 : Last dental visit in relation to perceived importance of child's oral health .............Table 4.5.2.12 : Age of child's first dental visit in relation to perceived importance of child's oral

health .....................................................................................................................

36263657177

7981

8283848485

858789

121122

123

124125

126

127

129130131133135137139

141143143

144

LIST OF TABLES

Child Health

VACCINATIONS

viii National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

Table 4.5.2.13 : Willingness to bring child to see dentist in relation to perceived importance ofchild's oral health ...................................................................................................

Table 4.5.2.14 : Ever received health personnel's advice on child's oral health in relation toperceived importance of a child's oral health .........................................................

Nutrition

BIRTH WEIGHT

Table 5.1.2.1 : Mean birth weight among children (below 5 years) by sociodemographiccharacteristics ........................................................................................................

Table 5.1.2.2 : Birth weight status among children (below 5 years) by sociodemographiccharacteristics ........................................................................................................

Table 5.1.2.3 : Low birth weight classification among children (below 5 years) bysociodemographic characteristics ..........................................................................

NUTRITIONAL STATUS OF CHILDREN (AGE < 5 YEARS OLD)

Table 5.2.2.1 : Mean Z score (weight for age, height for age, weight for height, BMI for age)among children (below 5 years) by sociodemographic characteristics ..................

Table 5.2.2.2 : Weight for age (WAZ) status based on WHO 2006 criteria among children (below5 years) by sociodemographic characteristics .......................................................

Table 5.2.2.3 : Height for age (HAZ) status based on WHO 2006 criteria among children (below5 years) by sociodemographic characteristics ........................................................

Table 5.2.2.4 : Weight for height (WHZ) status based on WHO 2006 criteria among children(below 5 years) by sociodemographic characteristics ............................................

Table 5.2.2.5 : BMI for age status based on WHO 2006 criteria among children (below 5 years)by sociodemographic characteristics .....................................................................

INFANT AND YOUNG CHILD FEEDING

Table 5.3.2.1 : Prevalence of early initiation and ever breastfeeding among infants below 6months by sociodemographic characteristics ........................................................

Table 5.3.2.2 : Prevalence of exclusive breastfeeding practices among infants below 6 monthsold by sociodemographic characteristics ................................................................

Table 5.3.2.3 : Prevalence of predominant breastfeeding practices among infants below 6 monthsold by sociodemographic characteristics ...............................................................

Table 5.3.2.4 : Prevalence of continued breastfeeding practices at 2 years among children at20-23 months by sociodemographic characteristics ..............................................

Table 5.3.2.5 : Median duration of breastfeeding among children aged 0-35 months old bysociodemographic characteristics .........................................................................

Table 5.3.2.6 : Prevalence of bottle feeding practices among children aged 0-23 months bycociodemographic characteristics ..........................................................................

Table 5.3.2.7 : Prevalence of age-appropriate breastfeeding practices among children aged0-23 months old by sociodemographic characteristics ...........................................

Table 5.3.2.8 : Prevalence of milk feeding frequency within 24 hours among children aged 0-23months old by sociodemographic characteristics ..................................................

Table 5.3.2.9 : Prevalence of minimum meal frequency, minimum dietary diversity, minimumacceptable diversity among children aged 0-23 months old by sociodemographiccharacteristics .......................................................................................................

Table 5.3.2.10 : Factors that influence the decision to stop breastfeeding among children 0-23months ...................................................................................................................

Table 5.3.2.11 : Milk feeding practice among children 0-23 months ...............................................

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167

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175176

National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings ix

Child Development

DEVELOPMENT DELAY

Table 6.1.2.1 : Percentage of children aged 6-59 months who were developmentally delayed ....Table 6.1.2.2 : Percentage of children aged 6-59 months who had gross motor developmental

delay ......................................................................................................................Table 6.1.2.3 : Percentage of children aged 6-59 months who had fine motor developmental

delay ......................................................................................................................Table 6.1.2.4 : Percentage of children aged 6-59 months who had speech/ hearing

developmental delay ..............................................................................................Table 6.1.2.5 : Percentage of children aged 6-59 months who had social skills developmental

delay ......................................................................................................................

SUSPECTED AUTISM

Table 6.2.2.1 : Prevalence of suspected autism among children aged 18-35 months ...................

ACCESS TO SCREEN TIME

Table 6.3.2.1 : Prevalence of any exposure to screen time for children aged 0-23 months andexposure more than 2 hours for children aged 24-59 months ...............................

Table 6.3.2.2 : Prevalence of any exposure to television in children aged 0-23 months ...............Table 6.3.2.3 : Prevalence of any exposure to computer/tablet/smartphone in children aged 0-23

months ...................................................................................................................Table 6.3.2.4 : Prevalence of any exposure to screen time (either television/ other than television)

in children aged 0-23 months .................................................................................Table 6.3.2.5 : Prevalence of exposure to television more than 2 hours a day in children aged

24-59 months .........................................................................................................Table 6.2.3.6 : Prevalence of exposure to screen time other than television more than 2 hours a

day in children aged 24-59 months ........................................................................Table 6.3.2.7 : Prevalence of exposure to screen time (either television/other than television)

more than 2 hours a day in children aged 24-59 months .......................................

EARLY CHILDHOOD CARE AND EDUCATION

Table 6.4.2.1 : Percentage of children age 36-59 months who are attending an organized earlychildhood education program .................................................................................

Table 6.4.2.2 : Support for learning as seen by percentage of children age 36-59 months withwhom adult household members have engaged in four or more activities thatpromote learning and school readiness during the last 3 days ..............................

Table 6.4.2.3 : Learning materials as seen by percentage of children under age 5 by numbers ofchildren's books present in the household, and by playthings that child plays with

CHILD PROTECTION

Table 7.1.2.1 : Inadequate care as seen by percentage of children under age 5 left alone or leftin the care of another child younger than 10 years of age for more than one hourat least once during the past week .........................................................................

Table 7.2.2.1 : Child disciplining methods experienced during the last one month among childrenaged 12-59 months ................................................................................................

Table 7.2.2.2 : Attitudes toward physical punishment as seen by percentage of respondents tothe child discipline module who believe that physical punishment is needed tobring up, raise, or educate a child properly ...........................................................

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186187

188

189

190

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197

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201

x National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

Maternal and reproductive Health

ANTENATAL CARE

Table 8.1.2.1 : Prevalence of mothers who attended antenatal care by number of visits duringpregnancy of last child birth ...................................................................................

Table 8.1.2.2 : Prevalence of mothers who attended antenatal care by timing of first antenatalvisit, during pregnancy of last child birth .................................................................

Table 8.1.2.3 : Antenatal care provider during pregnancy of last child birth ..................................Table 8.1.2.4 : Prevalence of mothers aged 15-49 years who received antenatal care in public

and private health facilities during pregnancy of last child birth ............................Table 8.1.2.5 : Prevalence of mothers aged 15-49 years who had undergone blood sample test,

health education, and ultrasound scan examination at least once as part ofantenatal care, during the pregnancy of last child birth .........................................

Table 8.1.2.6 : Prevalence of mothers aged 15-49 years who had undergone blood pressuremeasurement, urine sample test, abdominal examination at least once as part ofantenatal care during the pregnancy of last child birth ..........................................

Table 8.1.2.7 : Prevalence of mothers aged 15-49 years who had hypertensive disease, diabetes/gestational diabetes mellitus or maternal obesity during pregnancy of last child birth

Table 8.1.2.8 : Prevalence of mothers aged 15-49 years who had anaemia or heart diseasesduring pregnancy of last child birth ........................................................................

Table 8.1.2.9 : Prevalence of mothers aged 15-19 years who had childbearing and percentageof mothers who had their first pregnancy before aged 20 years in this survey ......

Table 8.1.2.10 : Prevalence of pre-pregnancy care among mothers aged 15-49 years who hadassociated medical conditions ...............................................................................

ASSISTANCE AT DELIVERY

Table 8.2.2.1 : Prevalence of safe and unsafe deliveries among mothers aged 15-49 years duringtheir last pregnancy ................................................................................................

Table 8.2.2.2 : Prevalence of mothers who received assistance during delivery of last child birth,by types of attendant ..............................................................................................

Table 8.2.2.3 : Prevalence of various types of persons cutting the cord ........................................Table 8.2.2.4 : Prevalence of unsafe delivery by birth attendants and place of delivery, during

their last child birth .................................................................................................

PLACE OF DELIVERY

Table 8.2.2.5 : Prevalence of mothers who delivered their last child by place of delivery .............Table 8.2.2.6 : Prevalence of mothers who delivered their last child by mode of delivery ............Table 8.3.2.1 : Awareness and practice of natural birthing as seen by percentage of mothers who

were aware of natural birth in this survey ..............................................................

POST-NATAL HEALTH CHECKS

Table 8.4.2.1 : Prevalence of mothers who had notified their delivery of last child to the nearestgovernment health facility ......................................................................................

Table 8.4.2.2 : Response to birth notification as seen by prevalence of mothers who receivedpostnatal home visits within 24 hours of birth notification, after the last child birth

Table 8.4.2.3 : Prevalence of mothers aged 15-49 years who received scheduled home visitsduring the first, second, and third to fourth weeks postnatal .................................

Table 8.4.2.4 : Prevalence of mothers aged 15-49 years who received at least one postnatalhome visit, by week ................................................................................................

Table 8.4.2.5 : Prevalence of mothers aged 15-49 years who attended clinics for postnatal careat one month postpartum .......................................................................................

Table 8.5.2.1 : Postnatal depression screening by positive Edinburgh Postnatal Depression Scale(EPDS) screening test among mothers aged 15-49 who have a child aged 6-16weeks .....................................................................................................................

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National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings xi

LIST OF ABBREVIATIONS

AAP : American Academy of PediatricsANC : Antenatal careARI : Acute Respiratory InfectionASD : Autism Spectrum DisordersBCG : Bacille Calmette GuerinBMI : Body Mass IndexCS : Caesarean sectionDPT-IPVHib : Diphtheria, Pertussis, Tetanus, Inactivated Polio Vaccine, Haemophilus

Influenza BEB : Enumeration BlockEPDS : Edinburgh Postnatal Depression ScaleGIVS : Global Immunization Vision and Strategy 20062015GVAP : Global Vaccine Action PlanHCP : Health care providersHep B : Hepatitis BIMCI : Integrated Management of Childhood IllnessesLBW : Low Birth WeightLQ : Living QuartersMCH : Maternal and Child HealthM-CHAT : Modified Checklist for Autism in ToddlersMDG : Millenium Development GoalsMICS : Multiple Indicator Cluster SurveyMOH : Ministry of Health MalaysiaMMR : Measles, Mumps, RubellaNHMS : National Health and Morbidity SurveyNOR : National Obstetric RegistrySCS : Survey Creation SystemSD : Standard DeviationSE : Side effectsSPSS : Statistical Package for the Social SciencesTBA : Traditional Birth AttendantUNICEF : United Nations Childrens Education FundWHA : World Health AssemblyWHO : World Health Organization

xii National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

IV. CHILD HEALTH

4.1 Vaccination

Contributors : Noor Ani Ahmad, Rohani Jahis, Aminah Bee Mohd. Kassim, Rozita Ab. Rahman, Mariam Jamaludin, RokiahMohamad, Sazidah Mohd Karli, Lim Kuang Kuay,Siti Norfadhilah Zainal Abidin, Santhi Ramasamy, Faridah Abu Bakar,Safurah Jaafar,Norazizah Ibrahim Wong, Tahir Aris

4.1.1 Introduction

The Millennium Development Goal (MDG) 4 aimed to reduce child mortality by two thirds between1990 and 2015 and immunization was an important component towards achieving this goal.1 Inaddition, the Global Vaccine Action Plan (GVAP), which was endorsed by the 194 Member States ofthe World Health Assembly in May 2012, targeted in delivering universal access to immunization.2WHO Member States have committed to four global immunization goals, (1) sustaining and achieveworld free polio, (2) meet global and regional elimination targets i.e. maternal and neonatal tetanuselimination, measles elimination, Hepatitis B accelerated control and Rubella elimination, (3) meet theimmunisation coverage target, and (4) introduction of new vaccines. In 2014, the Regional Committeefor the Western Pacific Region endorsed the Regional Framework of the Global vaccine Action Planin the Western Pacific which specified eight (8) goals: (1) sustaining polio-free status; (2) measleselimination; (3) rubella elimination; (4) maternal and neonatal tetanus elimination; (5) acceleratedcontrol of hepatitis B; (6) accelerated control of Japanese encephalitis; (7) introduction of newvaccines; and (8) meeting regional vaccination coverage targets.

The vaccination coverage targets set by the Global Immunization Vision and Strategy 20062015(GIVS), endorsed by the World Health Assembly in 2005 in resolution WHA58.15, were 90% nationalvaccination coverage and 80% vaccination coverage in every district by 2010.3 These targets havebeen maintained and further elaborated in GVAP as 90% national coverage and 80% coverage inevery district with three doses of DTP-containing vaccines by 2015, and 90% national vaccinationcoverage and 80% vaccination coverage in every district with all vaccines in national programmes,unless otherwise recommended, by 2020.

In Malaysia, the vaccination coverage target is set based on the goals and the availability of vaccinesin the facilities. As many vaccines are in combinations and the targeted diseases have different basicproduction (Ro), target for vaccination coverage is 95% for all. Health services in Malaysia areprovided by government as well as the private health facilities. So are the vaccinationion services.Currently, here is no single reliable system for tracking of each individuals vaccination status. Thus,a household nation-wide survey is important in the assessment of valid and reliable vaccinationcoverage of the country.

4.1.2 Findings

Out of 11,388 respondents eligible for this module, 10,140 responded to this survey, with a responserate of 89.0%. Comparison of the sociodemographic profiles of the two groups is shown in Table4.1.2.1. The percentage of non-citizen among those who did not respond to the survey was highercompared to the percentage of non-citizen among those who responded, but as the total non-citizeneligible for this study was only 4.2%, the impact to this difference was negligible.

1 http://www.who.int/topics/millennium_development_goals/child_mortality/en/2 http://www.who.int/immunization/global_vaccine_action_plan/GVAP_doc_2011_2020/en/3 http://www.wpro.who.int/about/regional_committee/65/documents/wpr_rc065_8_epi_corr1.pdf

2 National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings

Table 4.1.2.1 : Sociodemographic profile of household that responded vs households thatdid not respond

Responded to survey Not respondedNo. % No. %

Age of motherMean (years)

Ethnicity of childMalayChineseIndiansOther BumiputeraOthers

Citizenship of childMalaysianPermanent residentsNon-citizen

31.37 31.15

713612224371133212

997315152

62.814.04.512.76.0

95.40.44.2

60417371148250

11430

105

48.513.95.711.920.1

91.60

8.4

The profile of the respondents involved in this study is shown in Table 4.1.2.2. By ethnicity, the profileof those who were successfully interviewed was similar to the ethnicity by birth as reported by theDepartment of Statistics Malaysia. There is almost equal proportion by sex. Majority of the mothersof these children aged 25 to 39 years old. By marital status, 0.3% of the mothers were single, 2.5%of mothers and 2.5% of fathers had no formal education, with 7.2% earning less than RM1000 permonth.

In this study, only children aged 12-23 months were eligible to be interviewed, as they were expectedto complete their primary vaccination by then. Information on vaccination status was verified byimmunisation cards volunteered by the mothers. In such instances where the vaccination cards werenot available, the status of the vaccination was considered as self-reported by mothers.

Table 4.1.2.3 showed the prevalence of children aged 12-23 months who were vaccinated againstBCG. Majority of the children were verified to have received BCG vaccination except for 7.7% of thechildren. The prevalence of those children who did not receive BCG vaccination was highest inPahang (12.5%).

A total of 89.8% was verified to have received Dose 1 of DPT-IPV/Hib vaccine, 89.6% were verifiedto have received Dose 2 and 89.0% verified as completed the third dose of DPT-IPV/Hib vaccine. Self-reporting was 9.5% for all the three doses of DPT-IPV/Hib (Table 4.1.2.4). In the whole country 1.5%of the children aged 12-13 months did not received any DPT-IPV/Hib vaccination. Comparing betweenstates, Sabah showed the highest prevalence (2.8%), followed by Pulau Pinang (2.7%) and Selangor(2.1) whereas WP Putrajaya did not report any. The percentage of non-vaccinated children washighest for non-citizens at 7.1%, compared to Malaysians and those with permanent residence andthose with head of household without formal education was highest at 7.4% compared to othereducation levels.

Table 4.1.2.5 revealed that 92.2% of children aged 12-23 months were verified as received Dose 1of Hepatitis B vaccination, with additional 7.8% self-reported, while 89.8% were verified to havereceived Dose 2 of Hepatitis B, with additional 9.6% self-reported, and only 88.4% had completedthird dose of Hepatitis B vaccination with 9.9% was self-reported. Respondents who did not haveany Hepatitis B vaccination were found in Kedah, WP Kuala Lumpur, Kelantan, Pulau Pinang andMelaka. A total of 1.7% children aged 12-23 months did not complete Hepatitis B vaccination. Bystates, the highest prevalence was noted in Pulau Pinang (3.1%), followed by Sabah (2.8%) and WPKuala Lumpur and Kedah with 2.1% each. Those who did not complete Hepatitis B vaccination were

National Health And Morbidity Survey 2016 : Maternal And Child Health (MCH) Volume II : Findings 3

higher amongst non-Malaysians (6.9%) compared to Permanent Residence and Malaysians. Thosewith head of household without formal education had the highest incomplete Hepatitis B vaccination(6.5%) compared to other education levels.

A total of 87.3% of children aged 12-23 months were verified as having received MMR vaccination,with additional 9.3% self-reported as received MMR. Among those children aged 12-23 months, 3.4%were found as not vaccinated against MMR (Table 4.1.2.6). The prevalence was highest in WP KualaLumpur (6.0%), followed by Sabah (4.9%) and Selangor (4.7%). By profile, the non-vaccinated werehigher among non-Malaysian (10.5%), and those with head of household with no formal education(15.8%).

Overall, 86.4% children were verified as having received complete primary vaccination by the age of12 months, with an additional 8.9% self-reported as having completed their childs primaryvaccination. A total of 4.5% of children received some vaccinations but did not complete all scheduledprimary vaccination by the age of 12 months, and 0.1% had not received any vaccination (Table4.1.2.7). The prevalence of children with incomplete primary vaccination was highest in Selangor(7.3%), followed by WP Kuala Lumpur (7.2%) and Sabah (7.2%). Incomplete vaccination was higheramong those residing in urban areas as compared to those in rural areas (5.3% vs 2.9%). By profile,those who did complete their primary vaccination were those with mothers who do not have anyformal education (18.0%) and non-Malaysians (10.9%). Top three reasons given for incompletevaccination were lack of time (19.9%), the child being unwell (17.3%), and financial or geographicalbarriers (16.6%). A total of 1.3% were due to vaccine refusal, 4.0% refused vaccination, 2.4% worriedabout side effects, 2.1% did not trust the vaccine, 1.3% were doubtful about the halal status of thevaccine, 0.9% due to religious beliefs and 0.6% had a previous bad experience (all these wereconsidered as decision by themselves) (Table 4.1.2.8). 6.2% of those who did not complete theirprimary vaccination were due to different schedules used by private facilities, where MMR vaccinewas given later in life (Table 4.1.2.8).

A total of 6.2% children received more than 50% of their vaccination at private facilities. Theprevalence was higher in urban areas compared to rural areas (8.3% vs 2,0%). It was highest in WPKuala Lumpur (20.3%), followed by Selangor (14.4%) and Johor (5.8%). Examining the profiles ofthese children, they had mothers who had completed their tertiary education and with higherhousehold income (Table 4.1.2.9). Top three reasons given for their preference were; shorter waitingtimes (43.9%), only able to go to clinic for vaccination during weekends (22.0%), and panel doctors(20.6%), as shown in Table 4.1.2.10.

When asked about their source of information about vaccination, majority (89.4%) mentioned doctorsas their source, with 1% get information from electronic news or website and with 0.6% reportedsocial media as their primary source (Table 4.1.2.11). Majority of the mothers do not have concernon any vaccine. However 0.6% mothers had concern on MMR vaccine (Table 4.1.2.12). Majority ofthe mothers believe that vaccines are protective, can prevent spread of disease, and are safe; 98.5%,98.1%, and 98.2%, respectively.

Majority of them (98.5%) also reported that healthcare providers explained the side effects of thevaccine. They were also receptive towards the introduction of a new vaccine with 97.0 % response(Table 4.1.2.13).

4.1.3. Conclusion

In general, overall prevalence of children aged 12-23 months who completed their primary vaccinationwas more than 90%, however only 86.4% were verified with vaccination cards. Incomplete primaryvaccination was higher among those with low education and non-Malaysians. About one-fifth of thosewith incomplete vaccination were due to accessibility problems and one-tenth due to vaccine refusal.


4.1.4. Recommendations

i. To provide free primary immunization for all; irrespective of citizenship.

ii. To ensure all healthcare providers (including private healthcare providers) to follow Ministry ofHealth schedule for primary immunization.

iii. To establish an act or regulation for all children (under 5 years) to be immunized.

iv. To develop a single electronic database or registry of children immunization for ease of follow-up(tracking of vaccination status) and documentation.

v. To develop smart partnership between public and private facilities in providing services to public,particularly immunization services.


4.2 Neonatal Tetanus Protection

Contributors : Noor Ani Ahmad, Rohani Jahis, Aminah Bee Mohd. Kassim, Rozita Ab. Rahman, Mariam Jamaludin,Rokiah Mohamad, Sazidah Mohd Karli, Lim Kuang Kuay, Siti Norfadhilah Zainal Abidin, Santhi Ramasamy,Faridah Abu Bakar, Safurah Jaafar, Mohd. Azahadi Omar, Tahir Aris

4.2.1. Introduction

One of the MDGs target is to reduce by three quarters the maternal mortality ratio, with one strategyto eliminate maternal tetanus. Following on the 42nd and 44th World Health Assembly calls forelimination of neonatal tetanus, the global community continues to work to reduce the incidence ofneonatal tetanus to less than 1 case of neonatal tetanus per 1,000 live births in every district by 2015.

To assess the status of tetanus vaccination coverage, women who had a live birth during the twoyears before the survey were asked if they had received tetanus toxoid injections during thepregnancy for their most recent birth and their status was verified as recorded within their antenatalcards.

4.2.2. Findings

Out of 10,263 mothers interviewed, 7864 mothers (74.8%) had produced antenatal cards forverification. Based on the available cards, 96.4% had received tetanus vaccination (Table 4.2.2.1).Examining these mothers sociodemographic profile, the percentage was noted to be lower amongthose who had completed tertiary education level (93.9%), Chinese ethnicity (90.6%), those whowork in the private sector (93.3%), and those with higher household income (92.8%).

4.2.3. Conclusion

Overall, tetanus vaccination coverage was good but it was noted to be lower amongthose from highersocioeconomic background.


Ensure coverage of tetanus vaccination during pregnancy to all mothers irrespective of theirsocioeconomic background.


1. http://data.unicef.org/child-health/diarrhoeal-disease.html2. http://www.who.int/mediacentre/factsheets/fs330/en/3. http://www.who.int/mediacentre/factsheets/fs330/en/4. Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra RM. Association between intensive handwashing and child development in Karachi,

Pakistan: A cluster controlled trial. Arch Pediatr Adolesc Med. 2012 Sep4. UNICEF. Progress for children: A report card on water and sanitation. Number 5, September 2006.5. Black RE, Morris S, Bryce J. Where and why are 10 million children dying every year? Lancet. 2003;361(9376):2226-34.6. Park K. Epidemiology of Communicable Diseases. Parks Textbook of Preventive and Social Medicine. 21 st ed. Jabalpur: M/S Banarsidas Bhanot

Publishers; 2011. p. 156.

4.3 Care of Illness (Diarrhoea & Acute Respiratory Infections)

Contributors : Norhafizah Mohd Sahril, Sayan Pan, Fazly Azry Abdul Aziz, Azriman Rosman, Rozita Ab. Rahman, NorazizahIbrahim Wong, Tahir Aris

4.3.1 Introduction

UNICEF reported that diarrhoea is a leading killer of children, accounting for nine percent of all deathsamong children under age 5 worldwide in 2015.1 Diarrhoeal disease is the second leading cause ofdeath in children under five years old. It is both preventable and treatable. Globally there are nearly1.7 billion cases of diarrhoeal diseases every year and diarrhoea is the leading cause of malnutritionin children under five years old.2 Diarrhoea can have a detrimental impact on childhood growth andcognitive development.3 About 88% of diarrhoea-associated deaths are attributable to unsafe water,inadequate sanitation, and poor hygiene.4,5 Acute respiratory infection (ARI) in children less than 5years old is considered as one of the major public health problems and it is recognized as the leadingcause of mortality and morbidity in many developing countries. In young children, ARI is responsiblefor an estimated 3.9 million deaths worldwide, with 90% deaths due to bacterial pneumonia. In thedeveloping countries, seven out of 10 deaths happen due to ARI in under 5-year age group.6

4.3.2 Findings

4.3.2.1. Socio-demographic characteristics of children

There were 15,188 eligible respondents aged 0-59 months in this study. More thanhalf of respondents were males (51.9%) and 58.7% were children aged 24-59 months.By ethnicity, the majority were Malays (62.3%), followed by Chinese (15.9%), otherBumiputras (14.7%), and other ethnicities (2.2%). 36.2% of respondents were fromhigh income families of more than RM5000 followed by 17.9% from families withincome range from RM1000-RM1999, 13.5% from RM2000-RM2999 and the lowest7.5% from income less than RM1000 (Table 4.3.2.1).

4.3.2.2. Diarrhoea

The prevalence of diarrhoea in the past two weeks preceding the survey amongchildren aged 0-59 months was 4.4%. No significant difference in prevalence betweengender was observed. Children aged 12-23 months were reported to have had higherprevalence of diarrhoea (7.1%) as compared to children aged 0-11 months (5.2%) and24-59 months (3.2%), but the difference was not statistically significant. The OtherBumiputras had the highest prevalence at 8.8%, followed by Indians (5.3%), Others(5.0%), Malays (3.6%), and lastly, Chinese (3.3%). The prevalence was slightly higheramong Permanent Residents/ Non Malaysians (5.0%) compared to Malaysian citizensat 4.4%. Children whose parents received no formal education/primary were reportedto have higher prevalence of diarrhoea. Those children from the lowest householdincome (less than RM1000) were reported to have had higher prevalence of diarrhoea(7.3%) compared to others. As expected, the prevalence of diarrhoea among childrenfrom households with untreated water was highest at 12.5%, followed by unsanitary


waste disposal, 6.8% and unsanitary latrines, 6.2%. Among those children withdiarrhoea 45.0% were treated with ORS packets, while 41.4% received antibiotics, and25.5% received both (Table 4.3.2.2).

4.3.2.3. Acute Respiratory Infection (ARI)

This survey reported 0.9% of children aged 0-59 month have symptoms of acuterespiratory infection (ARI) in the past 2 weeks preceding the survey. The prevalencewas slightly higher in males at 1.1% compared to females at 0.8%. By age group, thehighest prevalence of ARI was noted among children aged 12-23 months (1.6%),followed by children aged 24-59 months (0.8%) and 0-11 months (0.6%). According tothe ethnic groups, Other Bumiputras had the highest prevalence at 2.6%, followed byothers (2.1%), Chinese (0.7%), Malays (0.6%), and Indians (0.3%). The prevalencewas higher among Permanent Residents/ Non-Malaysians (2.4%) compared toMalaysian citizens (0.9%). Children whose parents received no formal/ primaryeducation had higher prevalence of ARI. Children from the lowest household income(less than RM1000) were reported to have had higher prevalence of ARI (1.8%).Among those with ARI, more than half, (60.2%) were treated at public facilities, whilst31.4% from private facilities, 2.7% received treatment elsewhere and 5.5% did notseek any advice or treatment. Antibiotics were given to 62.8% of these children. (Table4.3.2.3).

4.3.2.4. Either one or both episodes of diarrhoea & ARI in the past two weeks

About 5.2% of children reported having had either diarrhoea or ARI in this study. Higherprevalence were observed among males (5.3%), children from age 12-23 months(8.3%), Other Bumiputras (10.5%), permanent residents/ non-Malaysian (7.5%) andparents with no formal or primary level education. The prevalence of children who hadboth diseases was 0.2%. No significant difference was observed between gender, ageand ethnicity. All children who had both diseases were Malaysian citizens (0.2%). Inaddition, parents with no formal or primary level education status were found to havechildren with the highest prevalence of both diseases. Children with the lowesthousehold income (RM1000-RM1999) were reported to have had higher prevalenceof diarrhoea and ARI (0.3%) (Table 4.3.2.4).

4.3.3. Conclusion

In conclusion, 4.4% of children aged 0-59 months were reported to have had an episode of diarrhoeain the past two weeks, 0.9% had symptoms of ARI, 5.2% had either diarrhoea or ARI; while 0.2% hadboth diseases.



Diarrhoea prevention :

Diarrhoea among children can be prevented and avoided by the following this measures.

i. Parents knowledge on hygienic practice is important particularly in food preparation for infantsand young children

ii. Basic hygiene standards such as proper hand washing, use of soap, safe food storage should bepractised by all households

iii. Proper sanitation & waste disposal and clean water supply should be in place to minimize the riskfor food and waterborne infections

iv. Use treated water or boiled water for drinking and food preparation

ARI prevention :

If any family members develop respiratory tract infection, it is important to take steps toprevent spreading the infection to other people especially other children. These stepsare outlined below.

i. Washing hands regularly and thoroughly, particularly after touching nose or mouth, and beforehandling food

ii. Judicious use of antibiotics in treating children with ARIiii. Practice good personal hygieneiv. Do not share personal belongings


4.4 Child Injuries

Contributors : Norhafizah Mohd Sahril, Sayan Pan, Fazly Azry Abdul Aziz, Azriman Rosman, Rozita Ab. Rahman,Norazizah Ibrahim Wong, Tahir Aris

4.4.1. Introduction

Injury to young children is a public health problem. The WHO has estimated that nearly 90% of injuriesto children are unintentional or accidental. Around 830,000 children die from such injuries everyyear, nearly 2300 each day1. It was found that for every death due to injury, there were severalthousand more children who survived with varying degrees of disability2. Children are particularlyvulnerable to injury because of their size, growth and development, inexperience and natural curiosity.The most common causes of childhood injuries are drowning, falls, fires or burns, poisoning,suffocation, and transportation-related injuries.3,4

4.4.2. Findings

This study is the first population-based study to assess child injury at home, outdoors and atcaretakers. This survey captured information on child injury aged 12-59 months. Overall, 3.8% ofchildren aged 12 to 59 months were reported to have injuries in the last one year preceding thesurvey. Prevalence of child injury was higher among boys (4.4%) as compared to girls (3.2%).Children aged 24-59 months reported to have higher prevalence 4.2% as compared to children aged12-23 months (2.9%). Among the various ethnicities, Chinese were reported as having the highestprevalence of child injuries (6.2%), while Other Bumiputera was (4.1%), Malays (3.4%), Indians(2.5%), and others (1.4%) respectively (Table 4.4.4.2).

By citizenship, Malaysians were reported to have a higher prevalence of child injuries (3.9%), followedby non-Malaysian (1.6%) and permanent residents (0.6%) respectively. The prevalence of childinjuries among children of married mothers was 3.9% compared to prevalence of child injury amongchildren of separated mothers; 1.5%.

Children of parents (both mothers and fathers) from higher educational level (4.9%) were reported tohave higher prevalence of injury compared to those with lower educational status. Children of motherswho were employed in private sectors had the highest prevalence of child injury; 6.1%. Children fromhouseholds earning more than RM5000 per month were reported to have a higher prevalence ofinjuries (5.9%). The majority of children (80.5%) sustained injuries inside the house, 13.3% outdoors,6.2% from other sites and there were no cases reported from caretaker facilities. A significantly higherpercentage of children from urban areas sustained injuries in the past one year (2.9%, 96% CI 2.00-4.10) compared to those from rural areas (1.0%, 95% CI 0.80-1.20).

4.4.3. Conclusion

The prevalence of injury among children 12 to 59 months was 3.8%. In general, injury happenedamong children from higher socioeconomic status, higher among boys and most of the time occurredat home.

1. Peden M, Oyegbite M, Ozanne-Smith J, et al. World Health Organization and UNICEF World Report on Child2. Injury Prevention. Geneva, Switzerland: World Health Organization; 2008.3. World Health Organization Report(2005) Child and adolescent injury prevention: A global to action4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. National Action Plan for Child Injury Prevention. Atlanta(GA): CDC, NCIPC; 2012



i. Better supervision of children

ii. Create child-friendly and safe environment

iii. Ensure child minders and care givers are properly trained

iv. Educate young parents on home safety and injury prevention

v. Public awareness and campaign


4.5. Care of Oral Health

Contributors : Yaw Siew Lian, Noor Aliyah Ismail, Natifah Che Salleh, Nurrul Ashikin Abdullah, Noor Ani Ahmad,Mohd Fuad Mohd Anuar, Che Fadillah Che Abd. Aziz, Sharifah Nur Hanis Syed Noh, Norazizah Ibrahim Wong, Tahir Aris

4.5.1. Introduction

Milk or baby teeth are important for many reasons. Not only are they needed to help children speakclearly and chew naturally, milk teeth are needed for the proper eruption of permanent teeth1. Toothdecay can happen at any age and it is important that healthy oral hygiene habits be started frombirth. The babys gum should be wiped with a clean moist gauze or wash cloth every day. Brushingshould commence as soon as the first teeth appear2. Up to 18 months of age, it is recommended thatthe babys teeth be brushed with plain water once a day after their last feed. From 18 months to 2years, it is recommended that parents begin teaching their child to brush their own teeth using a pea-sized amount of toothpaste. From 2 to 8 years, young children should brush their teeth twice a daywith parental supervision2.

It is recommended that parents bring their child for their first dental visit before the child is two yearsof age. Regular check up by the dentist is also advised to help diagnose and prevent tooth decay asearly as possible3. Taking into consideration the importance of beginning oral healthcare for youngchildren as early as possible, the Oral Health Division in the MOH has accorded high priority for oralhealthcare of toddlers (children below five years old) throughout the country. This programme startedas a pilot project in Sarawak in 1991 and subsequently expanded throughout the nation on an ad-hocbasis in the following years. The findings of the National Oral Health Survey of Preschool Children in2005 showed as high as 76.2% of 5-year-old preschool children had experience with dental caries4.Following this, in 2008, a national guideline was produced to create oral health awareness amongparents, child care providers and health personnel5.

4.5.2. Findings

The findings below relate to eight questions in the Oral Health Module of the NHMS 2016study, with areas of concern involving the perception of importance of oral healthcare for youngchildren, oral hygiene practices for them and dental visits.

Perception on importance of looking after childrens oral health

About 26.8% (95% CI: 21.55 32.76) of mothers reported that it was very important for themto look after their childs teeth, 72.8% (95% CI: 66.87 78.06) reported it was important, while0.3% (95% CI: 0.16 0.55) did not think looking after their childs teeth was important. A verysmall proportion (0.1%, 95% CI: 0.06 0.17) of mothers reported not knowing the importanceof looking after their childs teeth. Except for other ethnic groups, a significantly higherproportion of Other Bumiputeras (39.5%, 95% CI: 30.02 49.93) compared to Malays (23.3%,95% CI: 17.98 29.60), thought that looking after their childs teeth was very important (Table4.5.2.1).

1 http://www.bupa.com.au/health-and-wellness/health-information/az-health-information/looking-after-childrens-teeth (accessed on 31 May 2016)2 http://www.mouthhealthy.org/en/az-topics/b/Breastfeeding?source=Morning_Huddle (accessed on 10 June 2016)3 http://www.aapd.org/resources/frequently_asked_questions/?print=y (accessed on 10 June 2016)4 Oral Health Division. Ministry of Health Malaysia. National Oral Health Survey of Preschool Children 2005 (NOHPS 2005).5 Oral Health Division. Ministry of Health Malaysia. May 2008. Guidelines Early Childhood Oral Healthcare. Never Too Early To Start.


Frequency of cleaning/brushing childs teeth or supervision of a childs tooth brushing

About 74.0% (95% CI: 71.51 76.37) of mothers reported they cleaned/brushed their childsteeth or supervised their childs tooth brushing daily, while 19.0% (95% CI: 17.12 21.02)reported they had only done so once in a while. A low percentage of mothers (7.0%, 95% CI:5.74 8.49) reported they had never ever cleaned/brushed their childs teeth or supervisedtheir childs tooth brushing. The prevalence of mothers who reported not havingcleaned/brushed their childs teeth or supervised their childs tooth brushing every day wassignificantly higher among those in the 20 to 29 age group range (9.3% - 9.5%) as comparedto those aged 35 to 39 years (4.8%, 95% CI: 3.52 6.53). There was no significant differenceseen among the other sociodemographic variables (Table 4.5.2.2).

Prevalence of mothers who had never brought their child for a dental visit

About 73% (95% CI: 69.61 76.71) of mothers reported they had never brought their child fora dental visit (dental check up/ dental treatment) before. The prevalence was significantlyhigher among mothers who were students compared to those who worked in the public/privatesector, were self-employed or housewives (ranging from 62% - 75%). There was no significantdifference seen among other sociodemographic variables (Table 4.5.2.3).

Prevalence of mothers who had ever brought their child for a dental visit

Only about 26.7% (95% CI: 23.29 30.39) reported that they had brought their child for adental visit (dental check up/ dental treatment) before. There was no significant differenceseen among the other sociodemographic variables (Table 4.5.2.3).

Timing of childs last dental visit

Among mothers who had ever brought their child for a dental visit, about 77.0% (95% CI:73.91 79.88) had last taken their child for a dental visit (dental check up/ dental treatment)less than a year ago, while 17.5% (95% CI: 3.4 5.6) reported having done so in the last oneto two years and a small percentage, more than 2 years ago (4.8%, 95% CI: 3.76 6.00).About 0.7% (95% CI: 0.34 1.48) of mothers reported they could not remember when theyhad last taken their child for a dental visit. There was no significant difference seen among theother sociodemographic variables (Table 4.5.2.4).

Opinion on timing of childs first dental visit

About 38.3% (95% CI: 34.53 42.17) of mothers opined that they needed to take their childfor their first dental visit before their child turns two years of age, 27.5% (95% CI: 24.67 30.42) when their child is two to three years old and 25.3% (95% CI: 22.89 27.89) when theirchild is four to five years old. A further 9.0% (95% CI: 6.44 12.34) of mothers reported notknowing when they should take their child for their first dental visit. Significantly more mothersof Chinese ethnicity (14.5%, 95% CI: 9.72 21.01) reported not knowing the right timing of achilds first dental visit compared to the Indians (3.8%, 95% CI: 2.21 6.36). There was nosignificant difference seen among the other sociodemographic variables (Table 4.5.2.5).

Perception of age of a childs first dental visit

In this survey, a perception of age of a childs first dental visit was defined as good if themothers response was before two years of age and poor perception if the mothersresponse was other than before two years of age. Overall, about 58.0% (95% CI: 53.99 61.82) of mothers had a poor perception of age of their childs first dental visit. There was nosignificant difference seen among the other sociodemographic variables among mothers withpoor perception of age of a childs first dental visit (Table 4.5.2.6).


Willingness to take the child for dental treatment upon advice

The majority (99.2%, 95% CI: 98.74 - 99.44) of mothers reported that they would take theirchild for dental treatment upon advice. Only a small proportion (0.8%, 95% CI: 0.56 0.17)of mothers reported they were unwilling to bring their child for dental treatment. Significantlymore mothers in the age group 45 to 49 years (100%, 95% CI: 4.2 7.8) reported that theywould do so compared to mothers in the age group 30 to 34 years (99.7%, 95% CI: 99.29 99.86) and mothers aged 15 to 19 years (95.4%, 95% CI: 83.99 98.82). Notably, unemployedmothers (100%, 95% CI: 99.92 100.00) reported that they were willing to take their child fordental treatment compared to other occupational groups except housewives. There was nosignificant difference seen among the other sociodemographic variables (Table 4.5.2.7).

Reasons for not bringing a child for dental treatment

Among mothers who reported that they would not take their child for dental treatment uponadvice, the reasons cited were as follows; too young to get treatment (70.8%, 95% CI: 54.07 83.28), dental treatment for milk teeth was not important (11.2%, 95% CI: 3.44 31.07),the child was afraid of dental treatment (8.2%, 95% CI: 2.42 24.21). A further 6.9% (95%CI: 3.25 14.00) of mothers were opined that the dental clinic was too far (Table 4.5.2.8).

Prevalence of mothers who had ever received health personnelsadvice on childs oral health

Less than half of mothers (42.8%, 95% CI: 37.74 48.08) reported that they had previouslyreceived advice from health care workers on looking after their childrens oral health.Significantly more mothers working in the private sector (63.5%, 95% CI: 55.87 70.42)reported that they had never received advice from health care workers on looking after theirchildrens oral health compared to mothers working in the public sector (49.4%, 95% CI: 43.53 55.27). There was no significant difference seen among the other sociodemographicvariables (Table 4.5.2.9).

Perceived importance of child's oral health and dental visit

Among mothers who thought that it was very important to look after their childs oral health,only 23.8% (95% CI: 19.17 29.05) reported ever bringing their child for a dental check upor dental treatment. In addition, among mothers who thought it was important to look aftertheir childs teeth, only 25.3% (95% CI: 22.03 28.96) had taken their child for a dental visit(Table 4.5.2.10).

Perceived importance of child's oral health and last dental visit

Among mothers who thought that it was very important to look after their childs oral health,about 82.0% (95% CI: 76.21 - 86.71) reported ever taking their child for a dental check-up ordental treatment less than a year ago and 13.1% (95% CI: 9.34 18.14) had taken their childfor a dental visit one to two years ago. Among mothers who thought it was important to lookafter childrens oral health, about 75.1% (95% CI: 71.46 78.40) had taken their child for adental visit less than a year ago and 18.5% (95% CI: 15.95 22.27), one to two years ago(Table 4.5.2.11).

Perceived importance of child's oral health and age of child's first dental visit

Among mothers who thought that it was very important to look after their childs oral health,about 42.3% (95% CI: 37.16 47.54) thought that their childs first dental visit ought to bebefore two years of age. Meanwhile, among mothers who thought it was important to lookafter their childs oral health, about 36.8% (95% CI: 41.16 32.68) thought that their childsfirst dental visit ought to be before two years of age (Table 4.5.2.12).


Perceived importance of child's oral health and willingness to take children to see dentist

Among mothers who thought that it was very important to look after their childs oral health,99.2% (95% CI: 98.31 - 99.63) reported that they would take their child to visit the dentist ifadvised to do so. Among mothers who thought that it was important to look after their childsoral health, 99.1% (95% CI: 98.61 99.47) reported that they would take their child to a dentist(Table 4.5.2.13).

Ever received health personnels advice on childs oral health and perceivedimportance of a child's oral health

Among mothers who had ever received health personnels advice regarding care of theirchilds oral health, only 26.5% (95% CI: 22.24 31.15) thought that it was very important tolook after their childs oral health. Among mothers who had never received such advice, 27.0%(95% CI: 19.97 35.52) thought that it was very important to look after their childs oral health(Table 4.5.2.14).

4.5.3. Conclusion

The findings of this survey showed that only one in four mothers perceived that looking after theirchildrens teeth was very important. In addition to this, only about seven in ten mothers reportedhaving cleaned/ brushed their childs teeth or supervised their childs tooth brushing every day.Notably, seven in ten mothers reported they had never taken their child for a dental visit. Amongmothers who reported having ever taken their child for a dental visit, nine in ten mothers had soughtoral health care for their child in the last two years. Of concern, is the observation that only about fourin ten mothers were aware that they needed to take their child for their first dental visit before the ageof two years.

Almost all mothers reported that they would take their child for dental care if they were advised to doso. Among mothers who did not take their child for treatment when advised to do so, the mostcommonly reported reason was that their child was too young to get treatment. About four in tenmothers reported they had ever received advice regarding the care of their childs teeth from healthcare personnel.

This study also showed that among mothers who perceived that it was very important to look aftertheir childs oral health, only about one in four reported ever taking their child for a dental check upor for dental treatment. In addition to this, only two in five mothers who perceived that it was veryimportant to look after their childs oral health were aware that the childs first dental visit ought to bebefore two years of age. It was also observed that among mothers who had ever received healthpersonnels advice on their childs oral healthcare, only about one in four mothers perceived that itwas very important to look after their childs oral health.

Good oral health should begin from early childhood. In light of these findings, there is a strong needto promote greater awareness of the role of mothers in maintaining good oral health of their youngchildren. Advice for mothers on oral health should include good oral hygiene habits for the very youngchild as well as educating them on the right timing for their childs dental visit which is before the ageof two.



Taking into cognizance the findings of this survey, the following recommendations are proposed forpromoting good oral health among young children:

i. Strengthening oral healthcare programmes for toddlers.

ii. Strengthening collaborative efforts with other stakeholders and agencies to improve oral healthpromotion efforts and compulsory referral of toddlers (0 to 4 year olds) for oral health care.

iii. The following oral health messages are recommended to be disseminated amongstmothers/caregivers, towards good oral health among young children by health personnel, wherepossible:

a. It is very important to look after the milk teeth as soon as it erupts in the mouth.b. The childs teeth should be cleaned/ brushed every day.c. A child should have his/her first dental visit before the age of two.


V. NUTRITION

BIRTH WEIGHT, NUTRITIONAL STATUS & INFANT AND YOUNG CHILD FEEDING

Contributors : Azli Baharudin, Rusidah Selamat, Mohamad Hasnan Ahmad, Rashadiba Ibrahim, Junidah Raub,Jamilah Ahmad, Chin Yit Siew, Rashidah Ambak, Nor Azian Mohd Zaki, Nur Shahida Abdul Aziz, Fatimah Othman,Ruhaya Salleh, Madihah Ahmad Puaad, Cheong Siew Man, Syafinaz Mohd Sallehuddin, Norazizah Ibrahim Wong,Tahir Aris

5.1. BIRTH WEIGHT

5.1.1. Introduction

Birth weight is an important indicator of reproductive health and general health status of thepopulation. Low birth weight (LBW) has been defined by the World Health Organization (WHO) asweight at birth of less than 2,500 grams.1 A babys low weight at birth is either the result of a pre-termbirth (before 37 weeks of gestation) or of restricted foetal (intrauterine) growth. LBW is closelyassociated with foetal and neonatal mortality and morbidity, inhibited growth and cognitivedevelopment and development of chronic diseases later in life. In Malaysia, the LBW data has onlybeen reported as total number of infants regardless of the infants gestational age. Therefore, thissurvey was conducted to fill the gap on LBW data reported in the country.

5.1.2. Findings

Mean birth weight by sociodemographic characteristics

The overall mean birth weight for children below five years of age was 3.02 kg (95% CI: 3.01-3.04).Mean birth weight was significantly higher among males [3.05 kg (95% CI: 3.02-3.07)] than females[2.99 kg (95% CI: 2.97- 3.02)]. Full term infants mean birth weight was significantly higher [3.07 kg(95% CI: 3.05-3.08)] than pre-term infants [2.39 kg (95% CI: 2.32-2.47)]. Based on birth weightclassification, mean birth weight among extremely low birth weight infants (

As for those with normal birth weight, the highest prevalence was in Johor [94.3% (95% CI: 92.11-95.85)] and the lowest in Sarawak [83.8% (95% CI: 78.98-87.69)]. The prevalence among males was90.9% (95% CI: 89.64-92.01), whereby among females were 89.7% (95% CI: 88.22-91.05). Byethnicity, the highest prevalence of full term infants was among the Chinese [93.2% (95% CI: 90.59-95.07)] and the lowest was among Other Bumiputeras [84.9% (95% CI: 81.76-87.52) (Table 5.1.2.2).

Birth weight classification by sociodemographic characteristics

The overall prevalence for extremely low birth weight (

5.2. NUTRITIONAL STATUS OF CHILDREN (AGE < 5 YEARS OLD)

5.2.1. Introduction

Nutritional status is one of the important indicators of overall health status in children and may havea long-term health impact in their future life. Malnutrition is defined as failure of the body to obtainappropriate amount of energy and nutrients in order to maintain healthy tissues and organ function.While malnutrition in the form of wasting, stunting, and underweight can result from an inadequateintake of energy and nutrient intakes, overweight and obesity problems are a result of excessiveenergy intake1 (WHO, 1997).

There are four nutrition indices used to define nutritional status of children as measured throughanthropometric measurements (body weight and height), namely weight-for-age, height-for-age, bodymass index (BMI)-for-age and weight-for-height. Weight-for-age of the children reflects both acute andchronic malnutrition of the children, whereas height-for-age of the children is a measure of lineargrowth, in which reflects chronic malnutrition due to insufficient nutrition over a long-term period andrecurrent or chronic illness. As for BMI-for-age, it provides a good indicator for levels of body fat, andit is associated with an increased risk of non-communicable chronic diseases during childhood as wellas later in life. Based on WHO Growth Standard3 (2006) for children under 5 years old, weight-for-age

5.2.2.2 Nutritional status by height for age

In terms of height-for-age, about 76.0% (95% CI: 74.55-77.48) of the children were in the normalrange (Height-for-age: > -2SD to +2SD). The national prevalence of stunting (height-for-age: < -2SD) was 20.7% (95% CI: 19.34-22.12).

By age group, the highest prevalence of stunting was noted among those aged 24-35 months at23.5% (95% CI: 19.45-28.16) and the lowest was among children aged 6-11 months, 15.5% (95% CI:10.38-22.48). Among the various ethnicities of the child, those from Other Ethnicities showed thehighest prevalence of stunting [29.5% (95% CI: 22.15-38.09)], followed by Other Bumiputeras [24.9%(95% CI: 21.69-28.48)] (Table 5.2.2.3).

5.2.2.3 Nutritional status by weight for height

Overall prevalence of wasting among Malaysian children 59 months in this study was 11.5% [(95%CI: 10.51-12.65)]. The prevalence of wasting was higher among males [13.3% (95% CI: 11.72-15.06)]than females [9.7% (95% CI: 8.47-11.06)]. Based on age and ethnicity of the child, the highest wastingprevalence was observed among children aged 48-59 months old and children of Indian ethnicitywith a prevalence of 13.6% (95% CI: 11.47-15.95) and 17.3% (95% CI: 11.78-24.74) respectively.

The majority of Malaysian children in this survey had a body weight within the normal range 82.5%(95% CI: 81.04-83.79) while only 6.0% (95% CI: 5.09-7.07) were overweight. Prevalence of normaland overweight were higher among females than males. The findings of this survey also showed thatchildren aged 48-59 months showed the highest prevalence of overweight [7.7% (95% CI: 6.06-9.63)]and the lowest percentage of normal weight for height status [78.8% (95% CI: 75.96-81.37)] (Table5.2.2.4).

5.2.2.4 Nutritional status by BMI for age

The findings of the survey showed that the national prevalence of wasting (BMI for age< -2SD) was11.2% (95% CI: 10.21-12.27). Males showed a higher prevalence of wasting [12.9% (95% CI: 11.40-14.60)] than females [9.4% (95% CI: 8.22-10.76)]. By age groups, the highest prevalence was notedamong children aged below 5 months [13.3% (95% CI: 9.76-17.86)] and the lowest was amongchildren aged 24-35 months [9.6% (95% CI: 7.17-12.83)]. By ethnicity of the child, Indians showedthe highest prevalence of wasting [15.7% (95% CI: 10.84-22.16)], followed by Malays [12.0% (95%CI: 10.74-13.40)], and Chinese [10.2% (95% CI: 7.81-13.31)].

The overall national prevalence of overweight (BMI for age >+2SD) was 6.4% (95% CI: 5.40-7.49).The prevalence was higher among females [6.7% (95% CI: 5.07-8.70)] than males [6.1% (95% CI:5.07-7.26)]. By age groups, the highest prevalence was noted among children aged 24-35 months[9.2% (95% CI: 5.62-14.82)] and the lowest was among children aged below 5 months [2.3% (95%CI: 1.16-4.52)]. Among the various ethnic groups of the child, Chinese had the highest prevalence ofoverweight [7.0% (95% CI: 3.67-12.93)], followed by Malays and Other Bumiputeras respectively;6.4% (95% CI: 5.41-7.67) and 6.0% (95% CI: 4.31-8.29) (Table 5.2.2.5).

5.2.3. Conclusion

The prevalence of under nutrition that includes underweight, stunting and wasting among Malaysianchildren under five was much higher than the prevalence of overweight that warranted urgent andmore extensive strategies to address these problems.



i. To carry out an immediate comprehensive national landscape analysis on the nutritional status ofthe children in the country including stunting, wasting, underweight and overweight, so that moretargeted intervention can be executed

ii. Strengthen the multi-pronged strategies to address malnutrition among infants and young childrenthrough more aggressive nutrition advocacy and promotion as well as strengthening themanagement of malnutrition such as through management of severe and acute malnutrition andintegrated management of childhood illnesses (IMCI).

iii. To continue and strengthen the food and nutrition security of the children especially in addressingthe problem of wasting, underweight and stunting via more holistic and sustainable approaches.


5.3. INFANT AND YOUNG CHILD FEEDING

5.3.1. Introduction

Appropriate infant feeding practices are crucial for childrens survival as well as growth anddevelopment. An important part of infant feeding practices is breastfeeding, which plays a major roleas the first protection to prevent infant from infections, besides being an ideal source of nutrients,economic and safe. The global practice of early initiation of breastfeeding recommends that infantsshould be put to the breast immediately after birth within one hour without any disruption. This practicedetermined the successful establishment and durations of breastfeeding. Thus, the MalaysianNational Breastfeeding Policy1,2 was formulated in 1993 and revised in 2006 which states that allmothers are encouraged to breastfeed their babies exclusively with breast milk from birth until sixmonths of age and thereafter to continue until the child is two years old. Complementary foods shouldbe introduced only when the baby is six months old, and should be safe, solid, semi-solid or softfoods (age-appropriate feeding). Meal feeding frequency and dietary diversity should fulfil minimumacceptable diet and adequacy for both breastfeeding and non-breastfeeding children in ensuring thechildren nutrition needs.3

Therefore, in line with the UNICEFs Multiple Indicator Cluster Survey (MICS) conducted in variouscountries, this survey was also conducted in Malaysia since there are currently very limited nationalpopulation data on infant and young child feeding practices. The most recent reported populationdata on infant feeding was in the National Health and Morbidity Survey (NHMS 2006) which factorscontribute to duration of mothers breastfed their infants exclusively, information on the dietary diversityand adequacy of diet were not captured or addressed.

5.3.2. Findings

5.3.2.1. Breastfeeding

Prevalence of early initiation of breastfeeding among infants below 6 months old bysociodemographic characteristics

The overall prevalence of early initiation of breastfeeding within one hour of birth was 65.3%(95% CI: 61.42-68.88), initiation of breastfeeding within one day of birth was 24.3% (95% CI:20.84-28.02), initiation of breastfeeding after one day was 6.9% (95% CI: 5.19-9.18) andhaving never put the baby to the breast was 3.6% (95% CI: 2.55-5.01). The prevalence ofearly initiation of breastfeeding was significantly higher among mothers from rural areas[59.8% (95% CI: 70.79-80.42)] as compared to mothers from urban areas [75.9% (95% CI:54.71-64.67)]. In terms of ethnicity, the highest prevalence of early initiation of breastfeedingwas among Other Bumiputeras [88.1% (95% CI: 80.62-92.93)], followed by Malays [65.4%(95% CI: 60.69-69.84)] and the lowest among the Chinese [49.0% (95% CI: 36.42-61.67)].

In addition, the percentage of mothers who initiated early breastfeeding within one hour ofbirth was among those aged 45-49 years and the lowest was among mothers aged 40-44years old [27.1% (95% CI: 13.37-47.29)]. Comparing methods of delivery, mothers who hadvaginal delivery (assisted vaginal breech delivery) [99.5% (95% CI: 94.52-99.96)] had thehighest prevalence of early initiation of breastfeeding as compared to mothers who deliveredvia Caesarean section [49.0% (95% CI: 41.03-56.93)], or other assisted methods of deliverysuch as vacuum [35.2% (95% CI: 15.09-62.41)] and forceps [18.5% (95% CI: 2.23-69.41)].

1. MOH (Ministry of Health Malaysia) (2008b). Guidelines for the Feeding of Infants and Young Children, Ministry of Health Malaysia, Putrajaya2. Indicators for Assessing Breastfeeding Practice, Report of an Informal Meeting, World Health Organisation, Geneva, 19913. Indicators for assessing infant and young child feeding practices, Washington D.C., USA, 2007


In addition, mothers who delivered their babies at home had a higher prevalence of earlyinitiation of breastfeeding as compared to mothers who delivered at private facilities [54.2%(95% CI: 43.92-64.15)]. In terms of marital status, mother who were married/ cohabiting hada higher prevalence of early initiation of breastfeeding [65.3% (95% CI: 61.40-68.92)]compared to mothers who were separated /divorced/ widowed/ never married [31.4% (95%CI: 8.04-70.54)]. Mothers with primary education levels had a higher prevalence [71.2% (95%CI: 60.68-79.87)] of early initiation of breastfeeding than those with higher education levels[59.7% (95% CI: 52.84-66.28)]. On the other hand, mothers who were unemployed were morelikely to initiate breastfeeding within one hour of birth. The highest prevalence of early initiationof breastfeeding was among mothers from the income group of RM3000-RM3999 [72.2%(95% CI: 63.60-79.45)] while the lowest was 13.1% (95% CI: 6.14-25.93) among mothers withmonthly income less than RM1000 (Table 5.3.2.1).

Prevalence of exclusive breastfeeding practices among infants below 6 months old bysociodemographic characteristics

The overall prevalence of having ever breastfed was 98.1% (95% CI 96.23-99.04). The highestprevalence of having ever breastfed was among Indians [100% (95% CI: 100.00-100.00)],Malay [99.1% (95% CI: 97.85-99.60] and the lowest was among Chinese [96.4% (95% CI:89.93-98.74)]. On the other hand, mothers who were separated/ divorced/ widowed/ nevermarried had a higher prevalence of having ever breastfed (100%) than those who weremarried/ cohabiting [98.1% (95% CI: 96.18-99.03)]. In addition, there was no significantdifference on having ever breastfed by the methods of delivery. Mothers who were self-employed had the highest prevalence (100%) of having ever breastfed as compared tomothers working in the private sector [99.5% (95% CI: 98.09-99.87)] and public sector [98.6%(95% CI: 94.69-99.66)] followed by housewives [96.8% (95% CI: 93.01-98.60)]. Meanwhile,the highest prevalence of having ever breastfed by monthly income was seen in those withhousehold income of RM1000-RM1999 [99.7% (95% CI: 97.99-99.96)] while the lowest wasfrom those with household income RM5000 and above [96.0% (95% CI: 90.74-98.34)].

The overall prevalence of exclusive breastfeeding among infants under six months old was47.1% (95% CI: 43.13-51.18). By ethnicity, the highest prevalence of exclusive breastfeedingwas among Malays [48.9% (95% CI: 44.19-53.66)], followed by Other Bumiputera [46.0%(95% CI: 35.90-56.44)], Indians [41.8% (95% CI: 20.32-66.88)] and Chinese [29.6% (95% CI:16.48-47.19)]. In terms of marital status, mothers who were married/ cohabiting had a higherprevalence of exclusive breastfeeding [47.4% (95% CI: 43.36-51.45)] than those who wereseparated/ divorced/ widowed/ never married [24.3% (95% CI: 6.38-60.15)]. In addition,housewives [53.4% (95% CI: 47.79-58.99)] were more likely to exclusively breastfeed theirinfants as compared to those working in the public sector [46.0% (95% CI: 36.42-55.98)], andself-employed mothers [43.0% (95% CI: 27.96-59.42)]. Mothers who had primary educationlevels [50.7% (95% CI: 38.18-63.15)] and without education [50.2% (95% CI: 26.89-73.49)]were more likely to exclusively breastfeed their infant as compared to those with secondaryeducation [44.5% (95% CI: 38.60-50.56)]. In addition, the prevalence of infants under 6months who were exclusively breastfed was highest among the lowest household incomegroup of less than RM1000 [51.0% (95% CI: 38.38-63.52)] and the lowest was found amongthose with monthly household income of RM2000-RM2999 [41.0% (95% CI: 31.16-51.53)].However, there was no significant difference by sex of the children, citizenship of mother,marital status, occupation and education level of the mothers (Table 5.3.2.2).


Prevalence of predominant breastfeeding practices among infants below 6 months oldby sociodemographic characteristics

The overall prevalence of predominant breastfeeding among infants below 6 months was17.1% (95% CI: 14.33-20.31). The highest prevalence of predominant breastfeeding wasamong Malays [18.3% (95% CI: 14.94-22.17)] followed by Chinese [17.8% (95% CI: 8.92-32.24)] and Indian [13.5% (95% CI: 4.84-32.34)]. However, mothers who had higher educationlevels were more likely to predominantly breastfeed [21.4% (95% CI: 16.17-27.76)] comparedto mothers who had no formal education [18.2% (95% CI: 5.35-46.59)] and mothers who wereeducated up to primary school [14.7% (95% CI: 7.45-27.01)]. In terms of marital status, womenwho were separated/ divorced/ widowed/ never married had a higher prevalence ofpredominant breastfeeding [18.7% (95% CI: 4.22-54.61)] than mothers who weremarried/cohabiting [17.1% (95% CI: 14.29-20.32)]. On the other hand, mothers who wereworking in the private sector [22.1%, (95% CI: 15.75-30.06)] were more likely to predominantlybreastfeed as compared to those working in the public sector [17.40%, (95% CI: 11.87-24.87)],housewives [15.1% (95% CI: 11.47-19.63)] and mothers who were self-employed [(12.1%,95% CI: 5.67-23.95)]. In addition, the prevalence of infants predominantly breastfed washighest among those from household income of RM5000 and above [21.1% (95% CI: 15.70-27.77)] while the

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